OBSTETRICS AND GYNECOLOGY II

PRE-NATAL CARE
From Williams Obstetrics 24th edition
Breast and Skin Changes
LEGEND • Anatomical changes in the breasts that accompany
Lecture Powerpoint, Audio, Textbook pregnancy are characteristic during a first pregnancy
RED FONTCOLOR – MUST KNOWS!!! • Less obvious multiparas
PRENATAL CARE
“A comprehensive antepartum program involves a coordinated Fetal Movement
approach to medical care, continuous risk assessment, and psycho- • Maternal perception of fetal movement depends on factors
logical support that optimally begins before conception and extends such as parity and habitus
throughout the postpartum period and interconceptional period.” – • Multigravid – 16 and 18 weeks gestation
ACOG (2012) • Primigravid - ~20 weeks
• Examiner – ~20 weeks
ASSESSING PRENATAL CARE ADEQUACY
KESSNER INDEX PREGNANCY TESTS
• Commonly employed system and remains useful for • Detection of hCG in maternal blood and urine is the basis for
measuring prenatal care adequacy endocrine assays of pregnancy
• Incorporates three items from the birth certificate • hCG
o Length of gestation o produced by syncytiotrophoblast
o Timing of the first prenatal visit o amount increase exponentially during the fiist trimester
o Number of visits following implantation
• Does not measure the quality of care o α-subunit is identical to those of luteinizing hormone (LH),
follicle-stimulating hormone (FSH), and thyroid-stimulating
DIAGNOSIS OF PREGNANCY hormone (TSH)
o prevents involution of the corpus luteum
SIGNS AND SYMPTOMS ▪ principal site of progesterone formation during the rst 6
Amenorrhea weeks of pregnancy
• Abrupt cessation of menstruation in a healthy reproductive- o hormone can be detected in maternal serum or urine by 8
aged woman who previosly ha experienced spontaneous, to 9 days after ovulation – using a sensitive test
cyclical, predictable menses – highly suggestive of o doubling time of serum hCG concentration is 1.4 to 2.0
pregnancy days
• Not a reliable pregnancy indicator until 10 days or more after o serum hCG levels increase from the day of implantation
expected menses and reach peak levels at 60 to 70 days
o concentration declines slowly until a plateau is reached at
Lower-Reproductive-Tract-Changes approximately 16 weeks
• Chadwick sign – during pregnancy, the vaginal mucosa
usually appears dark-bluish red and congested SONOGRAPHIC RECOGNITION OF PREGNANCY
• Increased cervical softening • Transvaginal sonography
o Happens as pregnancy advances o Commonly used to accurately establish gestational age
o Estrogen-progestin contraceptives may cause similar o Confirms pregnancy location
softening • Gestational sac – first sonographic evidence of pregnancy
• fernlike pattern of mucus o Small anechoic fluid collection within endometrial cavity
o substantial increase in progesterone secretion associated o 4-6 weeks gestation
with pregnancy a ects the consistency and microscopic o normal gestational sac implants eccentrically in the
appearance of cervical mucus endometrium, whereas a pseudosac is seen in the midline
of the endometrial cavity
Uterine Changes • Pseudogestational sac / Pseudosac
• First few weeks of pregnancy o Fluid collection within endometrial cavity with an ectopic
o Uterine size grows principally in the anteroposterior pregnancy
diameter o further evaluation may be warranted if this is the only
▪ Feels doughy or elastic – during bimanual examination sonographic nding, particularly in a patient with pain or
• 6 to 8 weeks menstrual age bleeding
o Hegar sign • Intradecidual sign
▪ firm cervix contrasts with the now softer fundus o anechoic center surrounded by a single echogenic rim
▪ compressible interposed softened isthmus • Double decidual sign
▪ Isthmic softening may be so marked that the cervix and o two concentric echogenic rings surrounding the gestational
uterine body seem to be separate organs sac
• 12 weeks gestation • Pregnancy of unknown location
o uterine body is almost globular, with an average diameter o When sonography yields equivocal findings
of 8 cm o serial serum hCG levels can also help di erentiate a normal
• later in pregnancy intrauterine pregnancy from an extrauterine pregnancy or
o uterine souffle an early miscarriage
▪ soft, blowing sound that is synchronous with the maternal • middle of the fifth week
pulse o Visualization of the yolk sac confirms with certainty an
▪ produced by the passage of blood through the dilated intrauterine location for the pregnancy and can normally be
uterine vessels seen by the
▪ heard most distinctly near the lower portion of the uterus • after 6 weeks
o embryo is seen as a linear structure immediately adjacent
to the yolk sac
o funic souffle o cardiac motion is typically noted at this point
▪ sharp, whistling sound that is synchronous with the fetal
pulse • 12 weeks gestation
▪ caused by the rush of blood through the umbilical o crown-rump length is predictive of gestational age within 4
arteries days
▪ may not be heard consistently

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 PRE-NATAL CARE
INITIAL PRENATAL EVALUATION
• Prenatal care should be initiated as soon as there is a
reason- able likelihood of pregnancy
• Major goals
o de ne the health status of the mother and fetus
o estimate the gesta- tional age
o initiate a plan for continuing obstetrical care
DEFINITIONS
1. Nulligravida - woman who currently is not pregnant nor has
ever been pregnant
2. Gravida - woman who currently is pregnant or has been in
the past, irrespective of the pregnancy outcome
o With the establishment of the first pregnancy, she becomes
a primi- gravida, and with successive pregnancies, a
multigravida.
3. Nullipara – a woman who has never completed a pregnancy
beyond 20 weeks’ gestation
4. Primipara – woman who has been delivered only once of a
fetus or fetuses born alive or dead with an estimated length
of gestation of 20 or more weeks
5. Multipara - woman who has completed two or more preg-
nancies to 20 weeks’ gestation or more
o Parity is determined by the number of pregnancies
reaching 20 weeks
NORMAL PREGNANCY DURATION
• first day of the last normal menstrual period is very close to
280 days or 40 weeks
• Naegele rule – estimate of expected delivery date
o adding 7 days to the date of the rst day of the last normal
menstrual period and counting back 3 months
o a gestational age or menstrual age calculated in this way
assumes pregnancy to have begun approximately 2 weeks
before ovulation, which is not always the case
TRIMESTERS
• FIRST TRIMESTER – 0 to 14 weeks
• SECOND TRIMESTER – 15 to 28 weeks
• THIRD TRIMESTER – 29 to 42 weeks
• clinically appropriate unit is weeks of gestation completed
• clinicians designate gestational age using completed weeks
and days
PREVIOUS AND CURRENT HEALTH STATUS
• same essentials of history taking as in medicine
• detailed information regarding previous pregnancies is
essential
• mensttual history is also important
o varies based on frequency and duration of menses
o without a history of regular, predictable, cyclic,
spontaneous menses that suggest ovulatory cycles,
accurate dating of pregnancy by history and physical
examination is difficult
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• use of oral contraceptives (steroidal)
o Because ovu- lation may not have resumed 2 weeks after
the onset of the last withdrawal bleeding and instead may
have occurred at an appreciably later and highly variable
date, using the time of ovulation for predicting the time of
conception in this circum- stance may be erroneous
• Use of sonography in early pregnancy will clarify gestational
age in unpredictable situations
PERSONAL AND SOCIAL HISTORY
Psychosocial Screening
• psychosocial issues as nonbiomedical factors that a ect
mental and physical well-being – AAP and ACOG (2012)
• seek barriers to care, communication obstacles, nutritional
status, unstable housing, desire for pregnancy, safety
concerns that include intimate partner violence, depression,
stress, and use of substances such as tobacco, alcohol, and
illicit drugs
• should be performed on a regular basis, at least once per
trimester, to identify important issues and reduce adverse
pregnancy outcomes
Cigarette Smoking
• Numerous adverse outcomes have been linked to smoking
during pregnancy
o Potential teratogenic effects
o twofold risk of placenta previa, placental abruption, and
premature membrane rupture
o neonates born to women who smoke are more likely to be
preterm, have lower birth- weights, and are more likely to
die of sudden infant death syndrome (SIDS)
o Risks for spontaneous abortion, fetal death, and fetal digital
anomalies are also increased
o children who were exposed to smoking in utero are at
increased risk for asthma, infantile colic, and childhood
obesity
• Smoking cessation is advised
Alcohol
• Ethyl alcohol or ethanol
o potent teratogen that causes a fetal syndrome
characterized by growth restriction, facial abnormalities,
and central nervous system dysfunction
Illicit Drugs
• Agents may include heroin and other opiates, cocaine,
amphetamines, barbiturates, and marijuana
• Chronic use of large quantities is harmful to the fetus
• Well-documented sequelae include fetal-growth restriction,
low birthweight, and drug withdrawal soon after birth
Intimate partner violence
• a pattern of assaultive and coercive behav- iors that may
include physical injury, psychological abuse, sexual assault,
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progressive isolation, stalking, deprivation, intimidation, and
reproductive coercion (ACOG 2012)
CLINICAL EVALUATION
• A thorough, general physical examination should be
completed at the initial prenatal encounter
• Pelvic examination is performed as part of the evaluation
o Visualization of the cervix using a speculum
▪ Bluish-red passive hyperemia of the cervix is
characteristic, but not of itself diagnostic, of pregnancy
▪ Dilated, occluded cervical glands bulging beneath the
ectocervical mucosa—nabothian cysts—may
prominent
▪ e cervix is not normally dilated except at the external os
o Bimanual examination
▪ Completed by palpation
▪ special attention to
✓ consistency, length, and dilatation of the cervix;
✓ uterine and adnexal size;
✓ bony pelvic architecture; and
✓ any vaginal or perineal anomalies
• Lesions of the cervix, vagina, or vulva should be further
evaluated as needed by colposcopy, biopsy, culture, or dark-
eld examination
• The perianal region should be visualized, and digital rectal
examination performed as required for complaints of rectal
pain, bleeding, or mass
SUBSEQUENT PRENATAL VISITS
• Prenatal Visits
o 4-week intervals until 28 weeks,
o Every 2 weeks until 36 weeks
o Weekly thereafter
• Women with complicated pregnancies often require
return visits at 1- to 2-week intervals
PRENATAL SURVEILLANCE
Fundal Height
• Between 20 and 34 weeks, the height of the uterine
fundus measured in centimeters correlates closely with
gestational age in weeks
• Used to monitor fetal growth and amnionic fluid volume
Fetal Heart Sounds
• 10 weeks – detection of fetal heart sound; Doppler
ultrasound
• Normal FHT: 110-160 bpm
• Using a standard nonamplified stethoscope, the fetal
heart may be audible as early as 16 weeks
• Fetal heart was audible by 20 weeks in 80 percent of
women, and by 22 weeks, heart sounds were heard in
all.
Sonography
• Provides invaluable information regarding fetal
anatomy, growth, and well-being
SUBSEQUENT LABORATORY TESTS
• If initial results were normal, most tests need not be
repeated
• Fetal aneuploidy screening may be performed at 11
to 14 weeks and/or at 15 to 20 weeks
• Serum screening for neural- tube defects is offered at
15 to 20 weeks
• Increased risk for HIV acquisition during pregnancy,
repeat testing is recommended in the third trimester,
preferably before 36 weeks’ gestation
• Women who engage in behaviors that place them at
high risk for hepatitis B infection should be retested at
the time of hospitalization for delivery
• Women who are D (Rh) negative and are unsensitized
should have an antibody screening test repeated at 28
to 29 weeks, with administration of anti-D immune
globulin if they remain unsensitized
Group B Streptococcal Infection
• The Centers for Disease Control and Prevention
(2010b) recommend that vaginal and rectal group B
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PRE-NATAL CARE
streptococcal (GBS) cultures be obtained in all women
between 35 and 37 weeks’ gestation
Gestational Diabetes
• Laboratory testing between 24 and 28 weeks’
gestation is the most sensitive approach
Selected Genetic Screening
• Selected screening for certain genetic abnormalities
should be offered to those at increased risk based on
family history, ethnic or racial background, or age
be
NUTRITIONAL COUNSELING
WEIGHT GAIN RECOMMENDATIONS
• 20th century - limited to less than 20 lb or about 9 kg
o prevent gestational hypertension and fetal macrosomia
• 1970s - at least 25 lb or 11 to 12 kg to prevent preterm birth
and fetal-growth restriction
• The Institute of Medicine and National Research Council
(2009) revised its guidelines for weight gain in pregnancy and
continues to stratify suggested weight gain ranges based
on prepregnancy body mass index (BMI)
• There is irrefutable evidence that maternal weight gain during
pregnancy in influences birthweight
• Obesity in pregnancy
o significantly increased risks for gestational hypertension,
preeclampsia, gestational diabetes, macrosomia, cesarean
delivery, and other complications
• women with low weight gains in pregnancy
o higher risk for preterm delivery
o higher risk for small-for-gestational age newborns
SEVERE UNDERNUTRITION
• mid to late pregnancy nutrition deprivation
o children were lighter, shorter, and thinner at birth
o higher incidence of sub- sequent diminished glucose
tolerance, hypertension, reactive airway disease,
dyslipidemia, and coronary artery disease
• early pregnancy nutrition deprivation
o increased obesity in adult women but not men
o also linked to increased central nervous system anomalies,
schizophrenia, and schizophrenia-spectrum personality
disorders
• Barker hypothesis
o fetal programming – adult morbidity and mortality are
related to fetal health
WEIGHT RETENTION AFTER PREGNANCY
• Not all the weight gained during pregnancy is lost during and
immediately after delivery
• The more weight that was gained during pregnancy, the more
that was lost post- partum
• no relationship between pre- pregnancy BMI or prenatal
weight gain and weight retention
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• Accruing weight with age—rather than parity—is considered
the main factor affecting weight gain over time
RECOMMENDED DIETARY ALLOWANCES
• Certain prenatal vitamin–mineral supplements may lead to
intakes well in excess of the recommended allowances
• use of excessive supplements, which often are self-
prescribed, has led to concern regarding nutrient toxicities
during pregnancy
• POTENTIALLY TOXIC - iron, zinc, selenium, and vitamins
A, B6, C, and D
o Vitamin A (> 10,000 IU / day) may be teratogenic
• Vitamin and mineral intake more than twice the
recommended daily dietary allowance shown in Table 9-6
should be avoided
CALORIES
• pregnancy requires an additional 80,000 kcal, mostly during
the last 20 weeks
• a caloric increase of 100 to 300 kcal per day is recommended
during pregnancy
• is intake increase, however, should not be divided equally
during the course of pregnancy
o e Institute of Medicine (2006) recommends adding 0, 340,
and 452 kcal/day to the estimated nonpregnant energy
requirements in the first, second, and third trimesters,
respectively
PROTEIN
• basic protein needs of the nonpregnant woman are added the
demands for growth and remodeling of the fetus, placenta,
uterus, and breasts, as well as increased maternal blood
volume
• During the second half of pregnancy, approximately 1000 g of
protein are deposited, amounting to 5 to 6 g/day
• Most amino-acid levels in maternal plasma fall markedly,
including ornithine, glycine, taurine, and proline
o Exceptions (these increase): glutamic acid and alanine
• most protein should be supplied from animal sources, such
as meat, milk, eggs, cheese, poultry, and fish
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MINERALS
IRON
• approximate 1000 mg of iron required for normal pregnancy
o 300 mg are actively transferred to the fetus and placenta
o 200 mg are lost through various normal excretion routes,
primarily the gastrointestinal tract
• 500 mg incorporated into the expanding maternal hemoglobin
mass, nearly all is used after mid- pregnancy
o iron requirements imposed by pregnancy and maternal
excretion total approximately 7 mg per day
o Few women have sufficient iron stores or dietary iron
intake to supply this amount
• at least 27 mg of elemental iron supplement be given daily to
pregnant women
• at least 30 mg of elemental iron, supplied as ferrous
gluconate, sulfate, or fumarate and taken daily throughout the
latter half of pregnancy, provides sufficient iron to meet
pregnancy requirements and to protect preexisting iron
stores.
o is amount will also provide for iron requirements of lactation
• Large fetus or win gestation – 60 to 100mg
• Not necessary to provide iron supplements during first 4
months of pregnancy
o Slight iron requirements during this time
o Avoids risk of aggravating nausea and vomiting
• Ingestion of iron at bedtime or on an empty stomach aids
absorption and appears to minimize the possibility of an
adverse gastrointestinal reaction
Iodine
• Recommended daily iodine allowance is 220 μg
• use of iodized salt and bread products is recommended
during pregnancy  set the increased fetal requirements and
maternal renal losses of iodine
• Severe maternal iodine deficiency predisposes offspring to
endemic cretinism, characterized by multiple severe
neurological defects
Calcium
• pregnant woman retains approximately 30 g of calcium
• Most of this is deposited in the fetus late in pregnancy
• increased calcium absorption by the intestine and progressive
retention throughout pregnancy
• Efforts to prevent preeclampsia using routine calcium
supplementation have not proven efficacious
Zinc
• Severe zinc deficiency in a given person may lead to poor
appetite, suboptimal growth, and impaired wound healing.
• the recommended daily intake is approximately 12 mg
• low-birthweight infants of mothers who received zinc had
reduced risks of acute diarrhea, dysentery, and impetigo
• zinc supplementation did not bene fetal developmental
outcome
Magnesium
• Deficiency of this mineral as a consequence of pregnancy
has not been recognized
• during prolonged illness with no magnesium intake, the
plasma level might become critically low, as it would in the
absence of pregnancy
• Supplementation did not improve any measures of pregnancy
outcome
Trace Metals
• Copper, selenium, chromium, and manganese all have
important roles in certain enzyme functions
• most are provided by an average diet
• A severe geochemical selenium deficiency has been
identified in a large area of China
o frequently fatal cardiomyopathy in young children and
reproductive-aged women
Potassium
• concentration of potassium in maternal plasma decreases by
approximately 0.5 mEq/L by midpregnancy
• Potassium deficiency develops in the same circumstances as
in nonpregnant individuals.
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o Monitor weight gain (Goal:~25 to 35 lb in women with

Fluoride
• no evidence that supplemental fluoride during pregnancy is
beneficial
• fluoride metabolism is not altered appreciably during
pregnancy
• no additional benefits from maternal ingestion of fluoridated
water if the offspring ingested such water from birth
• Supplemental fluoride ingested by lactating women does not
increase the fluoride concentration in breast milk
VITAMINS
• Increased requirements for most vitamins are usually
supplied by any general diet that provides adequate calories
and protein except folic acid
Folic Acid
• Decreased incidence of neural tube defects
• more than half of all neural-tube defects can be prevented
with daily intake of 400 μg of folic acid throughout the
periconceptional period
• A woman with a prior child with a neural-tube defect can
reduce the 2- to 5-percent recurrence risk by more than 70
percent with daily 4-mg folic acid supplements the month
before conception and during the rst trimester.
Vitamin A
• Although essential, this vitamin has been associated with
congenital malformations when taken in higher doses
o malformations are similar to those produced by the vitamin
A derivative isotretinoin
o Beta-carotene, the precursor of vitamin A found in fruits
and vegetables, has not been shown to produce vitamin A
toxicity
• Vitamin A deficiency, whether overt or subclinical, was
associated with an increased risk of maternal anemia and
spontaneous preterm birth
Vitamin B12
• Maternal plasma vitamin B12 levels decrease in normal
pregnancy mostly as a result of reduced plasma levels of
their carrier proteins—transcobalamins
• Vitamin B12 occurs naturally only in foods of animal origin,
and strict vegetarians may give birth to infants whose B12
stores are low
• Excessive ingestion of vitamin C also can lead to a functional
deficiency of vitamin B12
• Low level of B12 preconceptionally, may increase risk of
neural tube defects, same as folate
normal BMI)
o Explore food intake by dietary recall periodically to discover
the occasional nutritional errant diet
o Give tablets of simple iron salts that provide at least 27mg
of elemental iron daily
o Give folate supplementation before and in early weeks of
pregnancy
o Provide iodine supplementation in areas of known dietary
insufficiency
o Recheck hematocrit or hemoglobin concentration at 28 to
32 weeks gestation to detect significant decreases.
COMMON CONCERNS IN PREGNANCY
A. Employment
• In other countries, the Family and Medical Leave Act
requires that covered employers must grant up to 12
workweeks of unpaid leave to an employee for the
birth and care of a newborn child
• In the absence of complications, most women can
continue to work until the onset of labor
• In physically demanding work, 20-60% increase in:
o pre-term birth
o fetal-growth restriction
o gestational hypertension
• Occupational fatigue (number of hours standing,
intensity of physical and mental demands,
environmental stressors
o increased risk of preterm premature
membrane rupture
• Adequate periods of rest should be provided
• Advise women with previous pregnancy complications
to minimize physical work
B. Exercise
• The American College of Obstetricians and
Gynecologists advises a thorough clinical evaluation
before recommending an exercise program.
• In the absence of contraindications:
o Engage in regular, moderate-intensity
physical activity for 30 minutes or more day
• Avoid exercises with a high risk of falling or abdominal
trauma
• AVOID SCUBA DIVING!  increased risk for
decompression sickness
• If with certain pregnancy complication, abstain from
exercise or limit physical activity

Vitamin B6 – Pyridoxine
• For women at high risk for inadequate nutrition—for example,
substance abusers, adolescents, and those with multifetal
gestations—a daily 2-mg supplement is recommended
• vitamin B6, when combined with the antihistamine
doxylamine, is helpful in many cases of nausea and vomiting
of pregnancy

Vitamin C
• recommended dietary allowance for vitamin C during
pregnancy is 80 to 85 mg/day—approximately 20 percent
more than when nonpregnant

Vitamin D
• Unlike most vitamins that are obtained exclusively from
dietary intake, vitamin D is also synthesized endogenously
with expo- sure to sunlight
• maternal deficiency can cause disordered skeletal
homeostasis, congenital rickets, and fractures in the newborn
• adequate intake of vitamin D during pregnancy and lactation
was 15 μg per day (600 IU per day)

PRAGMATIC NUTRITIONAL SURVEILLANCE

• ADVISE PREGNANT WOMAN TO
o Eat what she wants in amounts she desires and salted to
taste
o Ensure food is amply available for socioeconomically
deprived women

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C. Seafood Consumption • Oral-vaginal intercourse is occasionally hazardous.

• Fish – excellent source of protein, low in saturated
fats, and contain omega-3 fatty acids
• AVOID shark, swordfish, king mackerel, tile fish
o Because of potentially high methylmercury
levels
• It is recommended that pregnant women ingest no
more than 12 ounces or two servings of canned tuna
per week and no more than 6 ounces of albacore or
“white” tuna
• The Avon Longitudinal Study of Parents and Children,
however, reported beneficial effects on pregnancy
outcomes in women who consumed 340 g or more of
seafood weekly
Aronson and Nelson (1967) described a fatal air
embolism late in pregnancy as a result of air blown into
the vagina during cunnilingus.
G. Dental Care
• Examination of the teeth should be included in the
prenatal examination, and good dental hygiene is
encouraged
• Periodontal disease has been linked to preterm labor
H. Immunization

D. Lead Screening
• Maternal lead exposure has been associated with
several adverse maternal and fetal outcomes across a
range of maternal blood lead levels
o Gestational hypertension
o Spontaneous abortion
o Low birthweight
o Neurodevelopmental impairments in exposed
fetuses
• Blood lead levels ≥ 45 μg/dL are consistent with lead
poisoning  may be candidates for chelation therapy

E. Automobile and Air Travel

• Women should be encouraged to wear properly
positioned three-point restraints throughout pregnancy
o The lap portion of the restraining belt should
be placed under the abdomen and across her
upper thighs
o The belt should be comfortably snug
o The shoulder belt also should be firmly
positioned between the breasts
o Airbags should not be disabled for the
pregnant woman
• Air travel in a properly pressurized aircraft has no
harmful effect on pregnancy
• American Academy of Pediatrics and the American
College of Obstetricians and Gynecologists –
concluded that pregnant women can safely fly up to 36
weeks’ gestation
• Significant risks with travel, especially international
travel, are infectious disease acquisition and
development of complications remote from adequate
resources
F. Coitus
• Sexual intercourse is NOT harmful in HEALTHY
pregnant women
• AVOID if at risk for:
o Abortion
o Placenta previa
o Preterm labor
• Intercourse late in pregnancy specifically has not been
found to be harmful
*See Appendix for bigger pictures
I. Biological Warfare and Vaccines
• Smallpox vaccination
o Live attenuated vaccinia virus
o Fetal vaccinia infection – rare
o May result in abortion, stillbirth, or neonatal
death
o In nonemergency circumstances, smallpox
vaccination is contraindicated during
pregnancy and in women who might become
pregnant within 28 days of vaccination
• Anthrax vaccination
o contains no live bacteria and thus would not
be expected to pose significant fetal risk
J. Caffeine
• It is unclear if caffeine consumption is associated with
pre- term birth or impaired fetal growth
• The American College of Obstetricians and
Gynecologists has concluded that moderate
consumption of caffeine—less than 200 mg per day—
does not appear to be associated with miscarriage or

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preterm birth o antacids may provide considerable relief

• The American Dietetic Association (2008)
recommends that caffeine intake during pregnancy be
limited to less than 300 mg daily, or approximately
three 5-oz cups of percolated coffee.
K. Nausea and Vomiting
• Common complaints during first half of pregnancy
• Treatment of pregnancy-associated nausea and
vomiting seldom provides complete relief, but
symptoms can be minimized
• Eating small meals at more frequent intervals but
stopping short of satiation is valuable
• Mild symptoms:
o vitamin B6 given along with doxylamine,
AND/OR
o phenothiazine or H1-receptor blocking anti-
emetics
• In some, hyperemesis gravidarum develops—vomiting
so severe that dehydration, may cause severe
problems
o Electrolyte and acid-base disturbances
o Starvation ketosis
L. Backache
• Back pain complaints increase with progressing
gestation and are more prevalent in obese women and
those with a history of low back pain
• Severe pain also has other uncommon causes, such
as pregnancy-associated osteoporosis, disc disease,
vertebral osteoarthritis, or septic arthritis
• Acute strain or Fibrositis – muscular spasm and
tenderness
• Treatment:
o Tylenol may be used chronically
o NSAIDs for short courses to avoid fetal
effects
o Muscle relaxants (cyclobenzaprine or
baclofen)
▪ Aluminum hydroxide, magnesium
trisilicate, or magnesium hydroxide
alone or in combination
O. Pica and Ptyalism
• Pica - craving of pregnant women for strange food
• Craving for nonfoods such as ice—pagophagia,
starch— amylophagia, or clay—geophagia
• If strange “foods” dominate the diet, iron deficiency will
be aggravated or will develop eventually
• Ptyalism - profuse salivation
P. Sleeping and Fatigue
• Many women experience fatigue and need increased
amounts of sleep
• Due to the soporific effect of progesterone but may be
compounded in the first trimester by nausea and
vomiting and in the latter stages of pregnancy by
general discomforts, urinary frequency, and dyspnea
Q. Leukorrhea
• Increased mucus secretion by cervical glands in
response to hyperestrogenemia
R. Cord Blood Banking
• Public banks promote allogeneic donation, for use by
a related or unrelated recipient, similar to blood
product donation
• Private banks were initially developed to store stem
cells for future autologous use and charged fees for
initial processing and annual storage

M. Varicosities and Hemorrhoids

VARICOSITIES
• Femoral venous pressures in the supine pregnant
woman increase from 8 mm Hg early to 24 mm Hg at
term
• Treatment (varicosities):
o Periodic rest with leg elevation AND/OR
o Elastic stockings
• Surgical correction is NOT ADVISED during pregnancy
• Vulvar varicosities frequently coexist with leg
varicosities, but they may appear without other venous
pathology
• If these large varicosities rupture, blood loss may be
severe
o Treatment: specially fitted pantyhose
• With particularly bothersome vulvar varicosities, a
foam rubber pad suspended across the vulva by a belt
can be used to exert pressure on the dilated veins

HEMORRHOIDS
• Hemorrhoids are rectal vein varicosities and may first
appear during pregnancy as pelvic venous pressures
increase
• Symptoms: pain and swelling  relieved by topical
anesthetics, warm soaks, stool softening agents
• If with thrombosis of external hemorrhoids: incision
and removal of the clot under local analgesia

N. Heartburn
• Most common complaints of pregnant women and is
caused by gastric content reflux into the lower
esophagus
• Increased frequency of regurgitation during pregnancy
most likely results from upward displacement and
compression of the stomach by the uterus, combined
with relaxation of the lower esophageal sphincter
• Treatment:
o frequent but smaller meals
o avoidance of bending over or lying at

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IMMUNIZATION

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